EMS Legal Update

Why documentation is part of good patient care

The patient care report needs to clearly and consistently demonstrate that patients received good patient care

Do your crews provide good patient care? Most leaders of EMS organizations likely would respond with an unqualified “Yes!”

But for many EMS leaders, what they classify as “patient care” may be too narrow. Documentation is an integral part of patient care. Focusing solely on the clinical care and not on the documentation of that care can send the wrong message to your crews.

Unfortunately, many PCRs that we see are inadequate; woefully lacking in detail. What used to be thought of as “good enough” is clearly not acceptable in today’s compliance and enforcement climate, and with the ever-present threat of a medical malpractice lawsuit hanging in the air.

Part of patient care is documentation

Yet some providers fall short in understanding the definition of “patient care.” EMS leaders have allowed a culture to develop that believes a well-written PCR is somehow separate from and unrelated to the provision of “good patient care.”

Good patient care means taking care of the whole patient. Your crews need to understand that their responsibility does not end when they deliver the patient to their destination.

The quality of care that that patient receives over the next days, weeks or months could be directly impacted by the quality of their PCR documentation.

Other medical professionals will be making patient care decisions based specifically on the EMS PCR. In fact, for many patients, the last decision that is made based on the PCR is made by an auditor who determines whether that patient is covered financially.

Many patients pay for health insurance. When a patient has paid for coverage, but is deprived a benefit by an EMT or paramedic who has been entrusted with caring for that patient simply because of that crew member’s poor documentation, that is deficient patient care.

All share in the blame for poor documentation

While many EMS leaders put the blame for poor documentation solely on the crews, it is our experience that in many cases crew supervisors, middle-management and even those at the very top of the organization share in the blame. Yes, it is true that the crews write the PCRs, but it should come as no surprise that what you put up with, you end up with.

One of the primary reasons that many documentation problems exist is because the supervisory behavior that results in poor PCRs is tolerated. If the message your crews are receiving from their supervisors is, “I don’t know why we have to do all this stupid paperwork,” your crews will never consistently document good patient care.

Whether your crews provide emergency or non-emergency ambulance transportation, the provision of good patient care requires excellent, thorough and complete documentation of that patient encounter, with great attention to the details, for every patient, on every trip, every time.

Emphasize importance of the narrative

The importance of a well-written narrative on the PCR cannot be overemphasized. We often hear that crews are frustrated because they believe they are being asked to simply duplicate in their narrative information already documented in checkboxes and drop-down lists elsewhere on the PCR.

A well-written narrative will not simply duplicate information documented elsewhere. Instead it will paint in the details, and clearly describe why treatments provided were necessary.

“Per Protocol” does not explain why specific treatments were necessary. For example, a cardiac monitor is not necessary for a patient suffering from chest pains “because someone wrote a protocol.” A cardiac monitor is necessary for the patient because of chest pains that the patient described and that the patient rated on a pain scale – all of which is documented.

Check boxes collect data; Narratives paint pictures

A good narrative clearly documents the patient’s response to treatments. In other words, as a result of the treatment did the patient’s condition improve, decline or remain unchanged?

To a great extent, crews should see those checkboxes and drop downs as a reminder of the various aspects of this patient’s care that need to be developed and clearly documented in the narrative.

As CMS stated in the Federal Register of November 16, 2012:

“It is always the responsibility of the ambulance supplier to furnish complete and accurate documentation to demonstrate that the ambulance service being furnished meets the medical necessity criteria.”

A few of the specific areas where we commonly see insufficient PCR documentation are:

A complete, accurate and thorough description of the patient’s condition.

The patient’s mobility status.

How the patient was moved to the stretcher, and whether the patient was able to assist with the transfer.

Medical necessity for the ambulance transport. Were other means of transportation contraindicated, and if so why?

What type of services did the patient require at the destination that were not available at the point of origin (for interfacility transfers).

Why was the patient transported to the particular destination?

Medical necessity for procedures performed (Not just what was done, but why was it necessary?)

Objective rather than subjective documentation of findings. (The facts, not unsupported conclusions.)

Pain scale documented for every mention of pain.

Assignment of Benefits signature requirements met for 100% of transports, at the time of service. (This allows either a patient signature or that of a qualifying representative.)

Accurate documentation of odometer readings (to the 10th of a mile).

PCR’s carefully reviewed and signed by all transporting crew members.

Obviously, high quality patient care documentation is an absolute necessity from a compliance standpoint. EMS leaders must also remember that a complete and thorough PCR is really the only lasting evidence of good patient care.

So let us ask again, do your crews provide good patient care?

About the author

For over 15 years, Page, Wolfberg & Wirth has been the nation’s leading EMS industry law firm. PWW attorneys and consultants have decades of hands-on experience providing EMS, managing ambulance services and advising public, private and nonprofit clients across the U.S.

PWW helps EMS agencies with reimbursement, compliance, HR, privacy and business issues, and provides training on documentation, liability, leadership, reimbursement and more. Visit the firm’s website at www.pwwemslaw.com, call 877-EMS-LAW1 (717-691-0100) to talk to any of our attorneys and consultants or email Karen Kreider kkreider@pwwemslaw.com if interested in onsite compliance or documentation training.

PWW’s Ambulance Compliance Program Tool Kit is specifically designed to deal with the new overpayment refund rules with model forms and policies, a model compliance plan, code of conduct, and compliance training program.

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